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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880902
Report Date: 07/26/2022
Date Signed: 07/26/2022 12:53:11 PM

Document Has Been Signed on 07/26/2022 12:53 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:BUENA VISTA ASSISTED LIVINGFACILITY NUMBER:
331880902
ADMINISTRATOR:NEWCOMB, DOLLYFACILITY TYPE:
740
ADDRESS:1393 S. BUENA VISTA ST.TELEPHONE:
(951) 658-5160
CITY:HEMETSTATE: CAZIP CODE:
92543
CAPACITY: 49CENSUS: 38DATE:
07/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Griselda T. Garcia - AdministratorTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced for the purpose of completing the facility's Annual Inspection. LPA Colvin met with Administrator Griselda T. Garcia and advised of the purpose of the visit, and that the Annual Inspection will be limited to Infection Control only. Below is a summary of what was observed:

Infection Control: LPA Colvin went over COVID-19 best practices for infection control and prevention with Administrator Griselda T. Garcias, who LPA Colvin found to be successfully incorporating the several aspects of COVID-19 best practices. LPA Colvin confirmed with Administrator that the facility did not current ahve a Mitigation Plan or an Infection Control Plan. LPA Colvin will be issuing the facility a Technical Advisory Note instead of a deficiency, as the Administrator is currently working on submission and completion of the Infection Control Plan. Residents have hand sanitizer available to them, and the bathrooms were stocked with hand soap and paper towels. While touring the facility, LPA Colvin observed postings throughout the facility for cough etiquette, social distancing, and infection control. LPA Colvin requested to view the facility's PPE supplies (gloves, masks, and sanitizer, and isolation gowns), which was located in the Administrator's office, and LPA Colvin observed the facility to have a 30-day supply. LPA Colvin went over the various recommended training for facility staff with Administrator Griselda T. Garcia in relation to COVID-19 and confirmed that staff have been trained on various aspects of infection control, recognition of symptoms of COVID-19, and donning/doffing PPE.

LPA Colvin inquired as to if staff have been fit tested for N95 masks, and Administrator Griselda T. Garcia informed LPA Colvin that at this time staff have only been trained on donning/doffing PPE. LPA Colvin will be issuing a Technical Assistance Advisory Note during today's inspection for staff not being fit tested for N95 masks. LPA Colvin will not be issuing a deficiency for this item due to the facility not currently having any COVID-19 positive residents, and N95 masks only needing to be worn when a resident is COVID-19 positive or under observation while awaiting test results.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE: DATE: 07/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/26/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: BUENA VISTA ASSISTED LIVING
FACILITY NUMBER: 331880902
VISIT DATE: 07/26/2022
NARRATIVE
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LPA Colvin will be providing Administrator with the information for Provider Information Notice (PIN) PIN-21-10-ASC which contains resources for getting staff fit tested for N95 masks. LPA Colvin observed a sign-in sheet at the front door of the facility, and confirmed that visitors and staff are being screened for symptoms prior to entering the facility.

Other:
  • Reporting Requirements - LPA Colvin reviewed Community Care Licensing's data storage software and did not observe any notes for a COVID outbreak at the facility in June 2022. LPA Colvin asked the Administrator about how it was reported, and the Administrator stated they left a voicemail on the main line for Licensing, but did not receive a call back. LPA Colvin inquired as to if there was any additional reporting to Licensing, such as a Special Incident Report (SIR). Administrator Griselda T. Garcia stated that no such subsequent reports were made by herself (as she was out with COVID-19) or by other staff. Deficiency cited.

  • Licensing Fees - Prior to coming out to the facility, LPA Colvin pulled the facility's history for Licensing fees, and observed that the facility was past due for the annual fee for 2022 in the amount of $1,238.00. Deficiency cited.

  • Criminal Background Clearance - During LPA Colvin's inspection, LPA Colvin observed that Administrator Griselda T. Garcia was not on the facility's staff roster, which LPA Colvin had pulled from Guardian this morning. LPA Colvin additionally contacted Licensing Office staff to have them double check the Administrator's clearance status, and confirmed that while Griselda T. Garcia is cleared, she is not associated to the facility. LPA Colvin reviewed the Administrator's file at the facility and observed a request for Clearance transfer as well as additional documents that would be required to update the Administrator on file. The Administrator additionally had a copy of a receipt for mailing the documents out. LPA Colvin will not be citing a deficiency or issuing civil penalties as the Administrator submitted the documents as required, and they most likely have just not been processed yet.


An exit interview was conducted with Administrator Griselda T. Garcia and a copy of this report, LIC809D, and appeal rights were provided.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2022
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Document Has Been Signed on 07/26/2022 12:53 PM - It Cannot Be Edited


Created By: Crystal Colvin On 07/26/2022 at 12:18 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: BUENA VISTA ASSISTED LIVING
FACILITY NUMBER: 331880902

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/26/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87211(a)(1)(D)
Reporting Requirements: (a) Each licensee shall furnish…reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.: (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in at least one outbreak of COVID-19, which posed an immediate health and safety risk to persons in care. LPA Colvin learned that while the Administrator left a message for Community Care Licensing on a voicemail regarding the COVID-19 positive cases, no additional follow-up to ensure the report went through was made, including a written incident report.
POC Due Date: 07/27/2022
Plan of Correction
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Licensee to submit Statement of Understnading regarding the requirements for reporting COVID-19 cases, as well as submit the requested COVID-19 positive case summary (provided by LPA Colvin) for each case from the last outbreak. Statement of Understanding and Positive Case SUmmaries due by Plan of Correction date of 7/26/22.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Joel Esquivel
LICENSING EVALUATOR NAME:Crystal Colvin
LICENSING EVALUATOR SIGNATURE:
DATE: 07/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/26/2022 12:53 PM - It Cannot Be Edited


Created By: Crystal Colvin On 07/26/2022 at 12:23 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: BUENA VISTA ASSISTED LIVING
FACILITY NUMBER: 331880902

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/26/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.185(a)
Fees for license or applications; use of revenues; collected; denial or forfeiture: (e) The failure of an applicant for licensure or a licensee to pay all applicable and accrued fees and civil penalties shall constitute grounds for denial or forfeiture of a license. This requirement was not met by:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in one year of Licensing Fees (2022) which poses a potential safety risk to persons in care. LPA Colvin observed that the Licensee has not yet paid the annual fees for 2022, which are now past due in the amount of $1,238.00.
POC Due Date: 08/09/2022
Plan of Correction
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Licensee agrees to pay all fees due to Licensing and provide LPA Colvin with a self-certification of fees paid by the Plan of Correction date of 7/26/22.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Joel Esquivel
LICENSING EVALUATOR NAME:Crystal Colvin
LICENSING EVALUATOR SIGNATURE:
DATE: 07/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2022


LIC809 (FAS) - (06/04)
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